Provider Demographics
NPI:1801072756
Name:GREGORY A GIBSON M D P A
Entity type:Organization
Organization Name:GREGORY A GIBSON M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-824-3777
Mailing Address - Street 1:301 HEALTH PARK BLVD STE 322
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5771
Mailing Address - Country:US
Mailing Address - Phone:904-824-3777
Mailing Address - Fax:904-824-6050
Practice Address - Street 1:301 HEALTH PARK BLVD STE 322
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5771
Practice Address - Country:US
Practice Address - Phone:904-824-3777
Practice Address - Fax:904-824-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060293207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12553OtherBCBS
FLE95209Medicare UPIN
FL12553OtherBCBS